EQRO 101 for DMC-ODS in California Saumitra SenGupta, Ph.D. Executive Director, BHC-CalEQRO Rama Khalsa, Ph.D. SUD Cal-EQRO & Leslie Tremaine SUD Cal-EQRO Behavioral Health Concepts, Inc.

External Quality Review (EQR) - Background  Section 1932(c)(2)(A) of the Social Security Act  annual external independent review  Balanced Budget Act of 1997 (BBA)  Requires states to develop a quality assessment and improvement strategy that is consistent with the federal HHS standards.  Requires HHS to develop protocols for use in performance of independent, external reviews of the quality and timeliness of, and access to, care and services provided to Medicaid beneficiaries by Medicaid MCOs and prepaid inpatient health plans (PIHPs).  Federal Regulations 42 CFR Part 438, Subpart E  External Quality Review  §  Activities related to external quality review  EQR Protocols, September

EQR Activities  Four Mandated Activities  Protocol 1: Triennial Compliance Review – DHCS  Protocol 2: Annual Validation of Performance Measures (PM) – CalEQRO  Protocol 6: Annual Validation Performance Improvement Projects (PIP) - CalEQRO  Appendix V: Information Systems Capabilities Assessment (ISCA) – Applicable to Protocols 1,2,3,4,6 – CalEQRO 3

 Five Optional Activities  Protocol 4: Validation of encounter data reported by MCO/PIHP (Plans)  Protocol 5: Design and administration of a survey or validation of the results of a previously administered survey  Protocol 6: Calculation of performance measures – CalEQRO (These will be specific to BH – MH or SUD)  Protocol 7: Implementation of PIPs required by the State in addition to those conducted by MCO/PIHP (BH combined MH/SUD PIP possible)  Protocol 8: Implementation of focused, one-time studies of the MCO’s clinical and/or non-clinical services as directed by the State - CalEQRO EQR Activities 4

EQR – CMS Definitions Applicable to the Protocols  Quality means the degree to which the MCO increases the likelihood of desired health outcomes of its enrollees through its structural and operational characteristics and through the provision of health services that are consistent with current professional knowledge in at least one of the six domains of quality as specified by the Institute of Medicine (IOM) – efficiency, effectiveness, equity, patient-centeredness, patient safety, and timeliness. This is the definition of quality in the context of Medicaid/CHIP MCOs, and was adapted from the IOM definition of quality. 5

 Validation means the review of information, data, and procedures to determine the extent to which they are accurate, reliable, free from bias, and in accord with standards for data collection and analysis. EQR – CMS Definitions Applicable to the Protocols 6

 MCO means all managed care organizations, including PIHPs under a Medicaid and/or CHIP program. California Mental Health Plans are PIHPs. EQR – CMS Definitions Applicable to the Protocols 7

EQR – State Requirements  Validation and Analysis of:  Performance Measures (PMs)  DMC-ODS’s Performance Improvement Projects (PIPs)  DMC-ODS’s Health Information Systems (HIS) Capabilities  State and County Consumer Satisfaction Surveys 8

 Additional Items:  CFM members on review teams (Consumer,Family Member)  Focus groups with CFM, DMC-ODS Staff, Providers and Other Stakeholders  Special consultation to DHCS on quality and performance outcomes  Final written annual report of each DMC-ODS  Annual aggregate statewide report  Statewide report on DMC-ODS PM results  Annual report presentation  Develop and maintain a public website with EQRO relevant information EQR – State Requirements 9

 DMC-ODS Specialty Mental Health Services (SMHS) Coordination Efforts:  Seniors and Persons with Disabilities (SPDs) Project  Medi-Cal Managed Care Plans (MCPs)  Fee for Service Medi-Cal (FFS/MC)  FQHCs and RHCs  County Mental Health Plans (MHP)  Cal MediConnect (Medi-Medi)  Medi-Cal MCP Rural Health Initiative EQR – State Requirements 10

 Mandatory PMs:  Total beneficiaries served by each DMC-ODS  Total costs per beneficiary served by each DMC-ODS  Penetration rates in each DMC-ODS  Timeliness Measures (TBD)  Measure of Coordination (TBD)  Measure of Cultural Competence (TBD)  Total psychiatric inpatient hospital episodes, costs, and average length of stay EQR – Performance Measures 11

 Additional PM domains (five in year 1, nine in years 2-5):  Access (How quickly,-treatment on demand)  Client/Family/Community Engagement in Services  Services Appropriate to Need  Effectiveness of Services  Linkage to non-DMC-ODS Services and Supports EQR – Performance Measures 12

 New PIP Development and Validation tools are on CalEQRO website – part of the review preparation materials  The tools closely track each other in terms of the areas they cover  Each DMC-ODS will be required to have two active PIPs that were underway in previous 12 months  One clinical  One non-clinical EQR – Performance Improvement Projects 13

 Clinical PIPs might target  Prevention and care of acute and chronic conditions  High-volume services  High-risk conditions  Infrequent but high-risk conditions, services, or procedures  Populations with special health care needs EQR – PIP Guidelines 14

 Non-Clinical PIPs might target  Coordination of care  Appeals, grievances process  Access or authorization  Member services EQR – PIP Guidelines 15

 Activity 1 – Assess the study methodology  Activity 2 – Verify PIP study findings (optional)  Activity 3 – Evaluate overall validity and reliability of study results EQR – PIP Validation 16

1.Review the selected study topics 2.Review the study question(s) 3.Review the selected study indicators 4.Review the identified study population 5.Review the sampling methods (if sampling is used) 6.Review the data collection procedures 7.Assess the MCO’s improvement strategies 8.Review the data analysis and interpretation of study results 9.Assess the likelihood that reported improvement is “real” improvement 10.Assess the sustainability of documented improvement EQR – PIP Validation Activity 1 - Assessment of Study Methodology 17

 The key focus in this activity is validating the processes through which data needed to produce quality measures were obtained, converted to information, and analyzed  This is optional for States as this is a resource intensive activity EQR – PIP Validation Activity 2 – Verify Study Findings (optional) 18

 Following Activity 1 and Activity 2 (if performed), the EQRO will assess the validity and reliability of all findings to determine whether of not the State has confidence in the MCO’s reported PIP findings.  As studies generally have some weaknesses, the EQRO will need to accept threats to the accuracy of the PIP, and determine PIP generalizability as a routine fact of QI activities.  EQRO can report a level of confidence in its findings:  High confidence in reported PIP results  Confidence in reported PIP results  Low confidence in reported PIP results  Reported PIP results not credible EQR – PIP Validation Activity 3 – Evaluate and Report Overall Validity and Reliability of PIP Results 19

PIP Clinics  As part of its Technical Assistance program, CalEQRO will be offering Webinars/Presentations on PIPs from time to time.  Clinic 1 – PIP 101 – Concept and Ideas  Clinic 2 – From idea to a PIP including Study Question(s)  Clinic 3 – Defining and tracking consumer outcomes and indicators 20

PIPs and PDSA Cycles can be good buddies – wheels within wheels Improvement Strategies/ Interventions Study Question Development Topic Selection 21

Information Systems Capabilities Assessment (ISCA)  Practice Management  Electronic Health Records  Billing and Claims  Privacy, Security and Integrity of Systems  Clinician and Other User Interface  Provider Interface and/or Interoperability  Reporting Capabilities – CalOMS & UCLA, CSI, Outcomes,Etc  Integration of Appropriateness, Quality, Timeliness, Access and Outcome Measures 22

EQRO Review Cycle Annual Review Schedule By March 31 st, develop draft annual review schedule for next FY On-site review length determined by DMC-ODS size Review by DHCS Review by DMC-ODS Finalize annual review schedule Review Notification and Planning At least 60 days prior to review date – Notification sent to DMC-ODS At least 30 days prior to review date - DMC-ODS to identify contact person At least 30 days prior to review date - DMC-ODS to submit all required documentation During 30 days prior to review date – CalEQRO and DMC-ODS plan on-site visit During 30 days prior to review date – CalEQRO review all submitted documents and complete draft validation of PIPs DMC-ODS On-Site Visit Executive Leadership and Managers Supervisors and Line Staff Quality Management Staff/Analysts responsible for PIPs and PMs Contract Provider Executive Leadership and/or Supervisors/Staff IS, Billing/Claims, Operations and Fiscal Staff Beneficiaries and Family Members Program Site Visit(s) 23 Each Plan must complete ISCA and submit two PIPs, response to previous yea’s EQRO recommendations, and a list of significant initiatives and changes since prior EQR

EQRO Review Cycle (Contd.) Post-Site Visit Activities Post-site internal team discussions Follow-up with DMC-ODS contact on pending items, if any Finalize PIP validation IS report Quality reviewer submits draft report to CalEQRO leadership for review and edits DMC-ODS Annual Report 30 days post on-site review – submit draft to DHCS 60 days post on-site review – incorporate/address DHCS comments/concerns, if any 65 days post on-site review – issue draft report to DMC-ODS for review/comments/clarifications 90 days post on-site review – Issue final DMC-ODS report and post on CalEQRO Website Statewide Annual Aggregate Report By July 31 – submit draft to DHCS By August 31 – submit final to DHCS Once final report is approved, organize public presentation 24

Q & A. - Discussion Survey will follow – all counties 25